Organization

Scientific validation of psychodrama therapy

15 answers to EAP questions

Edited by Michael Wieser, Pierre Fontaine and Judith Teszáry

Introduction

Klaus Ottomeyer and Michael Wieser wrote in the nineties the psychodrama scientific validation paper for the Austrian Government, you will find it under https://www2.uni-klu.ac.at/claroline/160321 (Documents/Training/OeAGG/Informationspapier_ueber_die_methodenspezifische.rtf) in German and it is published (Ottomeyer & Wieser, 1996). The expert opinion on this you will also find under https://www2.uni-klu.ac.at/claroline/160321 (Documents/ Training/OeAGG/expert opinion), a letter to the state insurances, and an overview in European psychodrama research. In Germany exists documentation for the scientific board of psychotherapy (Burmeister, Leutz, & Diebels, n. d.) and a new textbook (Ameln, Gerstmann & Kramer, 2004). Jorda, Ottomeyer, Rabl, Schigutt and Wieser contributed articles in dictionary of psychotherapy (Stumm & Pritz, 2000), the Austrian handbook psychodrama therapy (Fürst, Ottomeyer & Pruckner, 2004) and to encyclopaedia of psychotherapists (Stumm, Pritz, Voracek, Gumhalter, & Nemeskeri, 2005).

The modality has to be scientifically valid, to be proved by answering the following fifteen questions:

1. Has clearly defined areas of enquiry, application, research, and practice. • Enquiry/research: There are different fields of research in psychodrama. Kipper and Ritchie (2003) did the last quantitative meta analysis. In press are qualitative analyses of case studies (Kipper), and a measurement tool for spontaneity (Kipper). Treadwell, Lavertue, Kumar, and Veeraraghavan (2001) revised the Group Cohesion Scale and the Personal Attitude Scale-II (Kellar, Treadwell, Kumar, & Leach, 2002). Sociometry is developed in the Social Network Inventory (Treadwell, Leach, & Stein, 1993). Wieser (2003, 2004) investigates differential psychodrama therapy research ordered on ICD-10. • Application/practice: Has even some application areas that are difficult areas for other psychotherapies, for instance psychosis, delinquents, mentally retarded, etc.

2. Has demonstrated its claim to knowledge and competence within its field tradition of diagnosis/assessment and or treatment/intervention. • Diagnosis/assessment and therapy are not necessarily separated. The same play can be used as a diagnostic instrument. Sociometric tests and the social atom are original diagnostic instruments. They can give a diagnosis on the level of the individual but also on the level of the group.There is a bibliography in diagnosis and sociometry under https://www2.uni-klu.ac.at/claroline/160321 (Documents/Diagnosis/Literature).

3. Has a clear and self-consistent theory of the human being, of the therapeutic relation and of health and illness. Lars Tauvon

J.L. Moreno early (in 1920-ies) formulated the very first human interpersonal theory. No mental activity is possible in a human being except in relation to another human being (Ottomeyer & Wieser, 1996). The least possible unity is the human dyad.

Even in total isolation a human being relates to inner representations of other people.

As a consequence he developed the idea of group psychotherapy, based on experiences already around 1920 and formulated this in 1931 at an American Congress of Psychiatry. It is based on the conviction that in a therapeutic group everyone can be the therapeutic agent of the other group members. Moreno described the phenomena of co-conscious and co-unconscious states in groups.

The (always ongoing) process between individuals Moreno called tele (distance?) and describes it as an inter-individual perceptual process involving feeling reactions of which transference is just one and a distorted form. The tele is originally described as the force that forms a sociometric network. Moreno’s research in the early thirties was focused on studying the sociometric structures of groups by the way of sociometric tests. A sociometric test is based on individuals choice of each other with regard to a specific criterion. This emphasis on the individual´s freedom to choose assigns psychodrama to the existential philosophical tradition originating from Kierkegaard, Heidegger et.al.

The personality theory of psychodrama is the theory of roles. Compared to the most elaborate theory, the psychoanalytic, role theory has much less emphasis on structure and psychic hierarchy and is much more polycentric and flexible and less adaptable for the labelling kind of diagnostic classification. Diagnostic classification is based on an analysis of a group member’s functioning role-repertoire.

Moreno defines the role as ”the functioning form the individual assumes in the specific moment he reacts to a specific situation in which other persons or objects are involved. The symbolic representation of this functioning form perceived by the individual and others, is called the role. The form is created by past experiences and the cultural patterns of the society in which the individual lives, and may be satisfied by the specific type of his productivity. Every role is a fusion of private and collective elements. Every role has two sides, a private and a collective side.” (Moreno, 1961, page?)According to Moreno there are psychosomatic roles (representing physiologic functions), social roles (representing cultural attitudes) and psychodramatic roles (representing intimate personal relations). Every role has a cognitive, an emotional and a behavioural aspect. The roles can be studied and analysed in the here and now on the psychodramatic stage.

The role analysis is a good estimation of an individual’s functioning level in his environment. In every situation the functioning of an adequate role is important. An abundance of adequate roles can be regarded as a measure of good health. A deficiency of adequate roles can be compared with the psychoanalytic concept of ego restriction. There are many role aberrations that can be considered diagnostic. Important roles can be underdeveloped or absent. Malfunctioning roles can have an overdeveloped character preventing more adequate roles from developing. Roles formed in childhood in relation to important persons often have an important – and not consciously understood – impact on relations between adults. This is the mechanism traditionally described as transference, also described in a clear way in transaction analysis.

Other important concepts of psychodrama are spontaneity and creativity. Spontaneity is defined by Moreno as the capacity to a new and adequate response in an old situation or an adequate response to a new situation. Spontaneity thus is the necessary factor for the creative response to happen. This means being guided by implicit knowledge. It can be compared with the concept kairos (Stern, 2004) which means the distinct moment of possibilities where immediate action is crucial for a positive outcome. In psychoanalysis the request for the client to follow the basic rule and the analyst’s “free floating attention” can be seen as examples of spontaneity, not involving physical action.

Another important concept is the “genuine encounter”. Most psychodramatic techniques are developed to favour role-encounters between the client and important others or between different inner parts (roles) of the client. In the therapeutic relation there is a more egalitarian relation. The patient in some way may conduct his therapy (content) but the psychodramatist is directing the process, the techniques. Psychodrama is usually a group therapy and the group members are co-therapists for each other. This emphasis on encounters as crucial for change Moreno shares with his contemporary, Martin Buber. Daniel Stern has later coined the word inter-subjectivity for the (mainly implicit) process, first studied between mother and child, later generalised to be the common characteristic of all meetings, not least in the therapy process, where it represents the “unspecific” non-verbal factor. Neuro-physiological research suggests a new type of nerve cell, “mirror neurons”, mirroring in the observer what the observed person does. This is postulated to be a genetic survival mechanism favouring communication and cohesion in the group.

The concept tele (mentioned above), Moreno’s early name for the inter-subjective process, is in accordance with these modern views based on observations and neurophysiology.

Psychodrama should also be regarded as precursor to systems theory because of the interpersonal approach, the early sociometric research on the structure of groups and the descriptions of social atoms and networks. These views have been further elaborated by the Australian psychodramatist Anthony Williams and by the British psychodramatist and family therapist Chris Farmer.

The psychodramatic criteria for health can be summarised as follows: • Development of functioning, flexible roles suitable to create an emotionally and socially satisfying life. • Development of spontaneity (which is probably genetically present at birth as a survival factor) which may have suffered because of environmental and emotional deficits. Moreno early developed “spontaneity tests”, standard life situations where the subject had to improvise a solution.

4. Has methods specific to the approach, which generate developments in the theory of psychotherapy, demonstrate new aspects in the understanding of human nature, and to ways of treatment/interventionLars Tauvon

Psychodrama took it’s origin from experimental theatre. That colours the techniques that are derived from drama. Moreno stated that he wanted to give the drama back (from the professional actors) to the ordinary man to use for his own purpose. Moreno was an indefatigable inventor of techniques, many of which have been used in the framework of other therapies, e.g. the hot seat technique in gestalt therapy, in cognitive therapy and family therapy.The psychodramatic stage represents in itself a constituent. It can be seen as the site for projection of the clients’ inner world to the outside. The advantage of the stage (besides the concretisation) is that it allows movement in time and space and between reality and fantasy. The scene setting, which implies physical movement, visualisation and occasional attention to “insignificant” but loaded things also activates the process of remembering and emotions, which may guide the direction of the drama. The drama itself consists of the clients playing improvised scenes with the help of the therapist and members of the group.

To be able to facilitate encounters and analyse important roles a number of techniques can be used:Role reversal is the most important technique and separates psychodrama from other kinds of role playing. It means fully taking the role of another person (and seeing himself from the perspective of that other person). Difficulties in performing this have a definite diagnostic value.The technique helps to expose projections, transference reactions and unconscious role/ counter-role constellations and – because of the dramatic action involved often provides instant insight and both emotional release and cognitive understanding (Catharsis).

Other techniques are doubling which can be used in many ways but mainly to focus on important hidden roles in the client. The mirror technique allows the client to see the interaction from an observing role, which can give him the insight about which role that would be adequate. Other important techniques are future projections and surplus reality which can be used to prepare for new situations and examine which roles would have been crucial for a better outcome of traumatic situations. The idea of creating more adequate roles to manage the future is similar to the examination of “exceptions” in solution focused therapy” (de Shazer)

Psychodrama pre-supposes active participation from the group members. To play a role in someone’s psychodrama is generally an important therapeutic experience that widens understanding and helps discover useful new roles. Most group members report strong empathetic feelings watching the drama thus having their own therapeutic process. The last moment in a psychodramatic group session is called the sharing, usually a condensed moment when the group members share what they have felt and experienced during the drama.

The process in an ongoing psychodrama group is principally similar to the process in any therapy group. A common experience is that the emphasis on dramatic action accelerates the progress and produces a more effective therapy.

Generally one can assume that the active techniques of psychodrama using implicit memory functions facilitate what Daniel Stern calls inter-subjective moments, necessary for developmental progress in clients as well as babies. As mentioned earlier the psychodramatic techniques are designed to facilitate interpersonal encounters through direct dialogue here and now and development of shared emotional moments nourished by implicit memory material from a number of sources, especially from body sensations and other senses. By these means an over-emphasis on explicit verbal material is less imminent.

Moreno introduced concepts of relation in reciprocityEmpathy, two-way empathy (Zweifuehlung), Tele. In a German expert opinion psychodrama therapy as scientific psychotherapy modality (Wissenschaftlicher Beirat Psychotherapie, 2001) you can read that they acknowledge some basic research in improvement of empathy, attribution and perception of a group.

5. Includes processes of verbal exchange, alongside an awareness of non-verbal sources information and communication

Psychodrama is an action method. The patient is not only speaking but representing and different ways are used to understand (and let him understand) his action and body expression: doubling, mirroring.

6. Offers a clear rationale for treatment/interventions facilitating constructive change of factors provoking or maintaining illness or sufferingLambert, Garfield and Bergin (2004) wrote that as common factors they found out: • Unlearning old response patterns and acquiring new ones: that you can read also in every psychodrama textbook defining spontaneity and creativity. • Caring relationship: J. L. Moreno, the founder of psychodrama, had tele as an aim that means two-way empathy. • Warmth • Support • Attention • Understanding • Acceptance • Cathartic release: For Moreno catharsis was an important factor. • Persuasion

More directive techniques and modalities are stated to be better (Lambert, et al., 2004, 812); psychodrama is a more directive method.

P.F. Kellermann (1992) wrote a book on therapeutic factors in psychodrama.Catharsis of integration is not only an abreaction or purgation of feelings e.g. your anger against your father, but a purification, reorganisation of the mind and an integration of feelings in a whole. You put your anger with some love of your father.

Action insight is more than an intellectual clarification; it is by taking the place and role of the father that we get insight in our relation.It is surplus reality because it permits you in some way to do things that are not possible in real life: you can see through the eyes of your father. In Austria Wieser (2002) wrote a paper on healing factors and a bibliographyhttps://www2.uni-klu.ac.at/claroline/160321 (Documents/healing factor). It is not easy to make a difference between healing factors in psychotherapy. Specific healing factors are directly connected with the psychotherapy modality. For psychodrama we can list the main techniques doubling, role reversal and mirroring. An unspecific healing factor is mostly the psychotherapeutic relationship, which works in every modality. Psychodrama has therefore the terms encounter and tele (a two-way empathy). Of course psychotherapists personality is a healing factor and the environment of a patient with its private and occupational social networks. All healing factors together works in combination.

7. Has clearly defined strategies enabling clients to develop a new organisation of experience and behaviour

Psychodrama can be a laboratory of human relations and permit an exploration and experimentation of interpersonal relations in past, present and future.

8. Is open to dialogue with other psychotherapy modalities about its field of theory and practiceLars Tauvon

There are quite a number of psychotherapists from different schools who have adapted psychodramatic techniques to their own theoretical framework. Jungian psychodrama has originated in Italy and Switzerland (Maurizio Gasseau, Giulio Gasca and Wilma Scategni in Italy, Hellmut and Ellynor Barz at Carl Gustav Jung Institut in Switzerland). Psychoanalytic psychodrama has a strong position in France. It’s most well known advocate in USA is Sandra Garfield. The main technique of Gestalt Therapy, the empty chair, is an adaption and ingenious development of Moreno’s original monodrama technique. Gestalt therapy was originally basically individual therapy in group but has developed in interpersonal direction using many of the psychodramatic techniques. In body oriented psychotherapy (Downing, 1996) ”gestalt dialogues” are used in a similar way to make interpersonal sense of the material awakened by the body work. Inversely, body techniques are frequently used, by psychodramatists (Carlos Chan, Ildri Ginn et.al).Quite a number of psychodramatists have had a psychoanalytic training first which has given a basis for fruitful dialogues and synthesis. Among them are the Argentinian psychodramatists Dalmiro Bustos and Monica Zuretti. Also Paul Holmes, British psychiatrist 1992 wrote an extensive book “The Inner World Outside” about how object relation theory can illuminate the practice of psychodrama. Lars Tauvon (2001) wrote an article “A comparison of psychoanalytic and psychodramatic theory from a psychodramatist’s perspective.”

In an earlier paragraph, the similarities between psychodrama and systems theory, are mentioned. Antony Williams from Australia wrote two books, “The Passionate Technique: Strategic Psychodrama with Individuals, Families and Groups” (1989) and “Forbidden Agendas”: Strategic Action in Groups” (1991) elaborating this theme. Chris Farmer, British psychiatrist and family therapist, wrote “Psychodrama and Systemic Therapy” (1995) and made special reference to his work with families. JL Moreno was one of the first to treat families (Austria in the twenties, USA in the thirties) and inspired among others Nathan Ackermann to his psychoanalytically based family therapy. Virginia Satir was a family therapy pioneer who also early adapted psychodramatic techniques and developed them.

Psychodramatic techniques are used in CBT (Cognitive Behavioural Therapy). This is quite understandable from the point of view that situational techniques are useful for behaviour modification, especially exposure techniques. In that sense they have since long been used within psychodrama settings.

To summarise: Classical psychotherapy is based on Morenian therapy and has since the 1920-ies developed based mainly on clinical experience and theoretical reasoning like most psychotherapies did. The early research was more sociological than clinical. There is a lack of controlled outcome studies and of course there are both ethical and practical difficulties to produce a design good enough to produce convincing figures. One can assume that the basic results from Garfield and Bergin about the importance of the personality of the therapist and the therapeutic relation rather than of the specific technique should be valid also for psychodrama. A common view based on subjective experience by the performers that psychodrama may be more effective than therapies relying to heavily on explicit material still remains to be demonstrated in figures and can so far not be used as a strong argument. Maybe process studies with help of video techniques would be a better way to throw light on the efficiency of psychodrama.

9. Has a way of methodically describing the chosen fields of study and the methods of treatment/intervention, which can be used by other colleagues

Some techniques of group and adult play are utilised in other creative ways and integrated by other therapeutic orientations.

10. Is associated with information, which is the result of conscious self reflection, and critical reflection by other professionals within the approach.

In the ’30ties Moreno developed a role theory inspired by the sociologist G.H.Mead.At the present time, some psychodramatists are inspired by the neurologists (mirror cells) and D. Stern (2004) in developing theories about doubling.

11. Offers new knowledge, which is differentiated and distinctive, in the domain of psychotherapy.

In addition to the answer to question 4 the German expert opinion psychodrama therapy as scientific psychotherapy modality (Wissenschaftlicher Beirat Psychotherapie, 2001) gave as an example that emotional change in role reversal could become a foundation for different psychotherapy modalities.

12. Is capable of being integrated with other approaches considered to be part of scientific psychotherapy so that it can be seen to share with them areas of common ground.

13. Describes and displays a coherent strategy to understanding human problems, and an explicit relation between methods of treatment/intervention and results.

The Effectiveness of Psychodramatic Techniques: A Meta-Analysis (Kipper & Ritchie, 2003)Reviewed by Michael Wieser, edited by David Kipper

An earlier survey of the effectiveness of psychodrama (e.g., Kipper, 1978; Kellermann. 1982; Rawlinson, 2000) found out that psychodrama promotes “ behaviour change with adjustment, antisocial and related disorders” (Kellermann, 1982) and “develop self-esteem, to change elements of their behaviour and to develop empathy and social relationships” (Rawlinson, 2000 in Kipper & Ritchie, 2003, p. 14). However, these surveys were qualitative analyses. The first, meta-analytic study of the effectiveness of psychodrama techniques was conducted by Kipper and Ritchie (2003).

Theoretically Kipper viewed psychodrama as a compendium of clinical procedures (techniques) that when put together, formed the psychodrama intervention. Kipper and Ritchie (2003) reviewed empirical studies published in the last 35 years (1965-1999 concerning the effectiveness of role reversal, doubling, strait role playing portrayals, and treatments that combined several psychodrama procedures (multiple techniques). They used a rather stringent inclusion criteria, which resulted in 25 publications that were admitted. The initial literature review included retrieval from Social Science Index and reading the articles in their original publications. Two independent judges selected the final list of the articles with interrater agreement of 92%. The articles selected did not include those dealing with sociometry. The psychodrama procedures techniques whose effectiveness seemed to have some experimental investigation fell into four categories: role reversal, role playing, doubling and multiple techniques.

Articles included techniques that were used intensively, that is, 3 to 10 minutes for role-reversal, 5 to 15 for strait role playing, and 3-15 minutes of doubling 3 to 15. The participants in these studies were clinical and non-clinical populations. Only 44% had multiple sessions. In calculating effect sizes the authors used pooled standard deviation. 25 studies generated 281 effects with a big sample size of 1,325.

The results show a moderate adjusted effect size of 0.95, which is congruent with the effect sizes seeing in meta-analyses of the effectiveness of traditional, verbal group psychotherapy. Role reversal yielded the largest effect followed by the double. The multiple techniques had small effects; role playing had nearly no effects.

The difference between the procedures (techniques) • Doubling is significant better than role reversal, multiple techniques and role playing. • Role reversal is significant better than multiple techniques and role playing. • Multiple techniques and role playing are equal.

Ordinarily, one would expect to find that the multiple techniques category would show the greatest effectiveness. Surprisingly, this did not happened. Probably this can be attributed to the small number of studies found in this category. Groups of mixed gender tended to have higher effect sizes than single gender groups. There were no significant differences between clinical and non-clinical participants. Surprisingly, the same feature was observed with regard to the number of sessions which ranged from 1 to 40. The authors identified several independent variables and predictors: “populations (students vs. other populations), gender (single vs. mixed), and number of sessions (one vs. more than one)” (Kipper and Ritchie (2003, p. 20). Role-reversal was used more with students and in single sessions. The Double was used more with clinical clientèle and in multiple sessions and single gender. It needs further investigations. Several limitations of the study were mentioned. First, of course, is the relatively small number of articles that are available for meta-analytic investigation. Second, the study was based only on articles published in English. Studies in other languages and unpublished studies were not included.(You may find the review including some additional tables in https://www2.uni-klu.ac.at/claroline/160321 (Documents/Treatment effects).

14. Has theories of normal and problematic human behaviour which are explicitly relates effective methods of diagnosis/assessment and treatment/ interventions

For instance theory of encounter and the technique of role reversal in therapy.

15. Has investigative procedures which are defined well enough to indicate possibilities of research.

Moreno is the founder of action research and sociometry. The topic of interpersonal relation and cohesion of a group is well investigated. It is recommended to use IIP (Inventory of Interpersonal Problems; Horowitz, Rosenberg, Bauer, Ureno & Vilasenor, 1988) and SASB (Structural Analysis of Social Behaviour; Mensen, 2002). As already answered for question 1 the topic of spontaneity is now measured by new instruments. The late Marianne Schneider-Düker (1989) was specialist in role analysis and observations of groups with SYMLOG (Systematic Multiple Level Observation of Group-models). This field of research should be reactivated. Research in psychotherapeutic relation could be combined with the psychodramatic term tele, which means a two-way empathy.